Getting It Right With the Adult ADHD Patient: An Expert Interview With Kenneth Steinhoff, MD

Getting It Right With the Adult ADHD Patient: An Expert Interview With Kenneth Steinhoff, MD

Editor's note:

Patients with attention deficit/hyperactivity disorder (ADHD) are coming to clinical attention in adulthood more and more frequently. Primary care providers and adult psychiatrists are likely to diagnose and initiate treatment for these patients. Although aspects of pharmacotherapy and other interventions are similar in children and adults, attention to important differences is critical to achieve good outcomes. To get state-of-the-art advice about treating adults with ADHD, Medscape's Randall F. White, MD, FRCPC, interviewed Kenneth Steinhoff, MD, Associate Clinical Professor, Child Development Center at the University of California, Irvine.

Medscape: In your experience, how does an adult with ADHD typically come to clinical attention?

Kenneth Steinhoff, MD: Commonly, adults with ADHD present with other affective complaints, most often depression or anxiety.^[1] Primary care providers and general psychiatrists are well trained in those conditions, and often their attention focuses on disorders of emotion, while ADHD may be overlooked. But a patient with ADHD who has difficulty performing or keeping on track may have reason to be anxious about his ability to perform, and someone with a lifetime of struggling to do well may be demoralized and present with depression. So if providers aren't attuned to the possibility of ADHD, they might miss it.

With recent media attention to adult ADHD, I think there are more and more patients who have seen an advertisement or who have a friend or child who has been diagnosed, and they may directly ask, "Do I have ADHD?"

Medscape: Although it's not considered as devastating as schizophrenia or severe mood disorders, research indicates that ADHD causes social and occupational impairment in affected adults.^[2] What should clinicians ask patients to gauge the severity of impairment?

Dr. Steinhoff: Impairments from severe mood disorders and schizophrenia are relatively obvious. The problems of adults with ADHD are more subtle but also have potentially destructive ramifications. Because of their subtle nature, there can be an assumption that behavior is willful. For example, if an adult with ADHD is not paying attention to a conversation, people may assume it's because he's not interested or he doesn't care. Also, many ADHD symptoms seem to invite moral judgment. For instance, someone who is chronically late, avoids paperwork, and makes careless errors may seem "irresponsible."

In general, ADHD in adults has significant repercussions and results in underachievements in 2 main domains, work and the social arena. For gauging severity of impairment, it's important to look in both those areas. Adults with ADHD may have had multiple jobs.^[2] Furthermore, they may prefer jobs that require more movement and less paperwork; desk jobs are extremely difficult for adults with ADHD. In the social realm, a string of problem relationships is common, and the divorce rate is higher in adults with ADHD.^[2] Finally, clinicians should look for other consequences such as traffic accidents, substance abuse, and encounters with the law, which are more common in adults with ADHD.^[2]

Medscape: Once the diagnosis of ADHD is established, which medications should be considered first-line choices for an adult patient?

Dr. Steinhoff: I think the data are clear that psychostimulants are the most effective intervention for adults with ADHD.^[3] It was once thought that adults with ADHD did not respond as well as children or adolescents to stimulants, but this was a problem with dosing. Now that we use appropriate doses, the response rates for adults are similar to children.

There are 2 classes of stimulants: the methylphenidate class and the amphetamine class; some adults respond better to one or the other, which is hard to predict. The longest-acting preparations are generally best, because of the difficulty with ups and downs of shorter acting agents and because of the difficulty remembering to take medication. For methylphenidate, the longest acting preparation would be the OROS preparation (Concerta; McNeil), and for amphetamine, it would be extended-release mixed amphetamine salts (MAS; Adderall XR; Shire). Each of those has duration of action of about 12 hours.

The nonstimulant atomoxetine (Strattera, Lilly) has US Food and Drug Administration (FDA) approval for treatment in adults, but it's important to know that its effect size is relatively small, about 0.4, and that it's a twice-a-day medicine.^[4]

Medscape: So is atomoxetine a second-line approach?

Dr. Steinhoff: I think most experts would say so.

Medscape: What are the considerations in dosing psychostimulants in adults?

Dr. Steinhoff: With stimulants, the higher the dose, the better the desired effect and the greater the likelihood of side effects. So, one should be aggressive with the dosing but very sensitive to side effects. Affective and mood blunting can occur with higher doses of stimulants, and dry mouth can sometimes be uncomfortable. These are dose-related side effects that might limit one's ability to dose higher, but generally one would want to dose as high as possible with tolerable side effects.

It's important to mention some numbers because clinicians may think they're dosing high when they're really not. In an open-label continuation study of MAS XR in adults,^[5] 41% were on 60 mg per day and around 39% were on 40 mg per day. In a randomized, controlled trial of adults treated with OROS methylphenidate, the average dose was 81 mg with standard deviation of 32 mg.^[6] Without this frame of reference, clinicians may be nervous about going over 54 or 72 mg of OROS methylphenidate.

Medscape: How do you counsel patients on the commonest adverse effects of psychostimulants, and do they diminish over the course of treatment?

Dr. Steinhoff: I tell them from the very beginning that the higher the dose, the better the effect, and that I want them to partner with me to look for beneficial effects as well as side effects. Common ones are diminished appetite, some difficulty sleeping at night, dry mouth, and sometimes irritability or blunting of mood. Typically, I titrate the medication starting with a low dose (36 mg Concerta, 20 mg Adderall XR), increasing it on an every-other-week basis, and carefully asking about side effects. If patients are having side effects, I tell them that the goal is to find the optimal dose; there's no need to suffer, but some side effects diminish over time if they can be tolerated temporarily at the beginning.

Medscape: Given recent attention in the media, patients may be concerned about the risk of cardiovascular adverse effects, so how do you monitor and advise patients about those?

Dr. Steinhoff: This is especially important in adults. In clinical trials, we've started recording pulse and blood pressure before doing anything else when an adult patient first comes in. A surprising number of patients have benign essential hypertension, which may be in part because adults with ADHD don't attend so well to their medical care. Psychostimulants can cause, on average, a blood pressure increase of 3 to 4 mm of mercury,^[7] and we carefully monitor blood pressure with every dose change to be sure to capture any outliers or anomalies.

Although we worry about blood pressure and pulse, the media attention has been on the risk of sudden death. For that concern, we use the American Heart Association screen.^[8] Without a history of sudden death in the family, syncopal episodes, presence of a heart murmur, Marfan syndrome, or any cardiac history or risk factors in the patient, we typically don't get an EKG in advance of treatment.

Medscape: If a patient is positive on the screening questions, would you refer him or her to a cardiologist?

Dr. Steinhoff: Yes, I'm much more inclined to refer the patient to a cardiologist. Adults, especially adult males over 50, do have heart attacks whether or not they're taking stimulants. It's important to see that they have good primary medical care as well.

Medscape: To monitor treatment response in children with ADHD, clinicians ask parents and teachers to complete rating scales. What approach do you recommend to monitor outcomes in adult patients?

Dr. Steinhoff: Rating scales are actually useful in adults, and we use them in clinical trials and clinical practice. Several exist,^[9] and our group is writing one up now, but it's not yet published. General questions tend to give you general answers, and adults may not be good observers of their own ADHD. Only with specific questions as you go through the rating scale do you and the patient get a good picture of positive changes.

It's difficult to arrange an external rater for adults, but when available it's very helpful. Even though a spouse may have an axe to grind, he or she is typically a much better observer than the patient. Even a coworker or a friend can give helpful input.

Another approach is to find target symptoms. At the outset of treatment, ask patients to name the 3 most important changes they hope to gain with the medication. Ask patients to be very specific so that you have a measurable symptom that's important to them and that they can track.

Medscape: How much time should the clinician persist with a trial of medication before switching to an alternative if the response seems suboptimal?

Dr. Steinhoff: Well, the most important thing is dosing — with too low a dose, one may get little effect and erroneously conclude that the medication is ineffective for that patient. In children, we often increase dose at 1-week intervals, but that's probably a minimum for adults because it's harder to observe symptom changes. At any rate, an adequate medication trial is not a matter of time per se as much as a process of careful observation of symptom change and dosing to optimal benefit and minimal side effects. Getting the process right is what matters.

If, at the optimal dose of the first medication, the patient has side effects without a dramatic benefit, one would switch medication class. For instance, starting with OROS methylphenidate, one would increase dose until side effects emerged, and if there was inadequate effect, switch to MAS XR. Adults are much better than children about reporting their experience and often are able to articulate subtle differences among different classes of medication and different doses.

Medscape: What's the longest study you're aware of that followed adults receiving psychostimulant treatment, and does one ever see tolerance or loss of efficacy over time?

Dr. Steinhoff: The longest study that I'm aware of is the MAS XR 2-year study.^[5] It was the FDA pivotal trial with an initial double-blind, placebo-controlled, forced-dose phase with 20, 40, and 60 mg. Patients continued in a 2-year open-label extension study with individualized dosing. Dose crept up slightly over the 2 years, which is not uncommon.

There's some debate as to whether some patients develop tolerance over time or whether expectations change, such that they grow accustomed to the experience on the medication and hope for a little bit more. It's not clear that it's really a biologic tolerance. If it is, I think it's in a small group and is a very small effect.

Medscape: What basic psychosocial interventions for adults with ADHD can you suggest for busy clinicians?

Dr. Steinhoff: If clinicians are too busy to do much themselves, they can refer patients to someone who can provide such service. Self-help groups like CHADD [Children and Adults with Attention Deficit/Hyperactivity Disorder]^[10] can be helpful. Also valuable is recruiting a concerned spouse, significant other, or family member to assist.

A number of simple and practical things can be helpful for adults with ADHD. If they tend to put things off and procrastinate, they can practice the habit of thinking about doing it now rather than doing it later. If they lose things, they need to establish that everything has a place and everything is in its place. Patients often need visual reminders rather than relying on memory. A simple system works best, such as a Palm Pilot or a single notebook rather than many sheets of paper. Such habits tend to counteract some of the ADHD symptoms, and a busy clinician can quickly rehearse them with a patient.

Finally, it's important for patients to do the tasks that require organization while the medication is working and to make a plan for the time when medication wearsoff.

Supported by an independent educational grant from McNeil Pediatrics